In the circumstances it is my statutory duty to report to During the inquest evidence was heard that: Mr Steer had been treated by a number of different clinicians with different expertise including members of the Cardiology team and the Surgical team: He was initially treated by the Surgical team on the surgical ward ad was stepped down to ward level care on the 15t He was then transferred to the Coronary Care Unit on the 18th followlng myocardial infarction: ii He continued to be reviewed both by the Surgical team and the Coronary Care team o a daily basis, however there was never any liaison between the Surgical Doctors and Coronary Care Doctors. Evidence was given by the treating Consultant Surgeon, who confirmed that from her experience communication does not work well between the Doctors on the Surgical team and the Coronary Care team. On basis of the evidence given I believe this could affect the care provided to patients; She stated that she was not aware of any policy in place within the Trust dealing with the communication between different specialist teams caring for patient who was under shared care: She explained that there would be benefits if review was carried out looking at the communications between Doctors when a patient is under shared care: concerns with regard to the following: That in circumstances where a patient is under the care of both the Surgical and Coronary Care teams, communication between the Doctors of those teams does not work well and could affect the treatment a patient receives which could lead to a future death_ I therefore request that review is undertaken of any policies and procedures in place dealing with the communication between doctors caring for patient where then is shared care between the Cardiology team and the Surgical team. I would also request that all members of Wrightington; Wigan and Leigh NHS Trust are made aware of the policies and procedures in place dealing with communication between medical staff when dealing with patients under shared care_ you: May. May the have

ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and believe you and/or your organisation have the power to take such action; YOuR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; 18th January 2017. I, the coroner , may extend the period_ Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a CopY of my report to the Chief Coroner and to the following Interested Persons: (1) Mr Steer's wife on behalf of the family Iam also under a to send the Chief Coroner a copY of your response: The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send copy of this report to any person who he believes may find it useful or of interest; You may make representations to the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner: Dated Signed 23r November 2016 Rachael C Griffin duty me,